“Mrs. Dagenhart, why don’t you bring Noah over here and we’ll take a look at his x-rays.”
I flipped the switch of the view-box, back-lighting the films of the three-year-old’s wrist. She walked up behind me, carrying her young son.
“I know most parents aren’t used to looking at x-rays,” I told her, pointing to a buckled area in one of the bones of his wrist. “But that’s where he broke it.”
She leaned closer, peering at the film. “Oh good. At least it’s not fractured.”
Say what? Broken, fractured, cracked. They’re all the same thing, and all have the same implications.
We encounter another common misconception on an almost daily basis.
“Andrew fell at the skating rink and hurt his arm. We wanted to get it x-rayed, but there’s probably nothing wrong, since he can move it.”
Not so fast. Just because someone can move an injured finger, wrist, arm, or ankle doesn’t mean it’s not broken. It could even be fractured or cracked. Movement doesn’t mean anything, though this medical wisdom is ingrained in many of us. Just like “starve a cold and feed a fever.” Or is it “feed a cold and starve a fever?”
Pediatric bones and joints pose a unique set of problems and potential pitfalls. The good news is that most boney injuries in children do very well, with the right attention and treatment. Kids heal quickly, and broken bones do as well. As an example, a fractured wrist in a forty-year-old will take four to six weeks to resolve, assuming there is good alignment and immobilization. A four-year-old’s wrist will heal in a little as three weeks, again with adequate immobilization. And the healing is more complete, with less chance of resultant arthritis or limitation of movement. For instance, if I saw that forty-year-old ten years from now with another hand or forearm injury, I would probably ask him, “When did you break your wrist?” His bone might have completely healed, but you would forever be able to tell where it was broken. Not so with the four-year-old. In as little as a year, you wouldn’t be able to find the site—it’s remodeling having resolved any tell-tale sign.
Interesting stuff, and important. Kids’ fractures usually do well, properly diagnosed and treated.
Here’s another significant orthopedic term for the parents of young children: a green-stick fracture. You’ve probably heard of that, or maybe a buckle or torus fracture. This usually occurs in any of a child’s long bones (forearm, humerus, lower leg) and conceptually is more of a stress/bending of a bone, rather than a complete break. If you or I fell on ice and landed on our out-stretched hand, we would probably snap one of the bones in our wrist—usually the radius. A child might also slip and fall, land on his wrist or hand, and that bone would be “broken,” but not in two. Think of holding a small limb from a dogwood tree and bending it. Rather than cracking apart (like an old, dry stick), it bends and frays, but doesn’t completely separate. One side usually remains intact. That’s what frequently happens with a child’s bone, and is the reason they heal so quickly. Again, it has to be diagnosed and treated appropriately, and sometimes manipulated a little to make sure the alignment is corrected. But usually, the key for most of these injuries is immobilization and a little time.
There are several important pediatric orthopedic issues that we’ll need to consider, but right now, let’s take a look at one of the most common boney problems we encounter and what you need to know about it.
“Jeffrey and his brother Robbie were on their trampoline this afternoon, and Jeffrey came into the house holding his shoulder. We can’t find Robbie, so we really don’t know what happened.”
Trampoline. Hm… that and the skateboard had to be invented by an orthopedist.
“Okay, let’s take a look,” I told the anxious mother.
Jeffrey whimpered while I gently examined his shoulder and clavicle. There was a tender, swollen area over the mid-shaft of his collar bone, and a couple of x-rays defined the problem.
“He’s broken his clavicle,” I told his mother. “But he’s going to do fine. Everything else looks good, and he’ll need an arm sling for a couple of weeks, and some ice and Tylenol. Just try to keep him as quiet as possible until this has healed. And off that trampoline.”
Jeffrey was five-years-old, and this was another of those green-stick fractures. The bone was broken, but bent and not separated. It was going to do great. Most clavicle fractures do, until we reach our mid to late teens and beyond. Then the bone frequently breaks in two. That can sometimes happen with a younger child, but the treatment and outcome will usually be the same. An orthopedist once told me that with a complete fracture of a clavicle in a child Jeffrey’s age, “All you have to do is get the two ends in the same room and it will heal great.” Not so with a nineteen-year-old or adult. These injuries are more complicated beyond childhood, and can frequently require surgery to repair.
But not with Jeffrey, or the majority of these fractures in our pediatric patients.
I hope you noticed the recommended treatment for this injury—a simple arm sling. A lot of parents think that something more needs to be done—after all, this is a fracture, isn’t it? We used to do something more—a figure-of-eight bandage that wrapped behind a child’s neck and under his armpits. We would cinch this up as tight as possible, pulling those shoulders back as much as we could. Really painful for the child and completely unnecessary. More complications, pain, and frustration, and no difference in healing and or good outcomes. In hindsight, it seems pretty barbaric. A simple arm sling. If you find yourself in an ER or clinic and someone tries to do anything more than that, have them read this.
And you might ask the healthcare provider if he knows the difference between a fracture, a break, and a crack.
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This is an excerpt from the new book I’m writing with pediatrician Dr. Robert Alexander. The book will address 100 questions from parents regarding their children’s health. Feel free to email us with questions: askthedox@yahoo.com
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